Reality check of using the surgical safety checklist: A qualitative study to observe application errors during snapshot audits.

Abstract

The WHO Surgical Safety Checklist (SSC) was established to address important safety issues and to reduce the number of surgical deaths. So far, numerous reports have demonstrated sub-optimal implementation of the SSC in practice and limited improvements in patient outcomes. Therefore, the aim of this study was to audit the SSC-practice in a real-world setting in a university hospital setting. From 2015 to 2016, independent observers performed snapshot audits in operating theatres and shadowed the three phases of the SSC. Using a 4-point Likert-scale to rate the compliance on each audit day, we generated a report highlighting possible improvements and provided feedback to the operating team members. Audits were performed on 36 operating days (2015: n = 19; 2016: n = 17), in which a total of 136 surgical interventions were observed. Overall, the percentage of "very good compliance" improved from 2015 to 2016: for the sign-in from 52.9% to 81.2% (p = 0.141), for the team-time-out from 33.3% to 58.8% (p = 0.181), and for the sign-out from 21.4% to 41.7% (p = 0.401). The qualitative review revealed inconsistencies when applying the SSC, of which the missing documentation of an actually performed item or the wrong timing for an item was most common. Snapshot audits revealed that SSC compliance has improved over the observed period, while its application revealed inconsistencies during the three phases of the SSC. Snapshot audits proved to be a valuable tool in the qualitative analysis of SSC compliance and gave more insight than a mere completeness check of ticks in SSC documents.